Divorce Mediation Questionnaire

Divorce Mediation Questionnaire.

Please fill this out even if you think you have answered these questions on a prior intake form with this office.

1. Your full name _____________ and Maiden Name._______________ DOB._____

2. Place of birth._________. SS#_________ Date of Marriage ________

3. Place of Marriage _________________ Date of Separation ___________

4. Did you complete High School Y/N If yes, What is your highest grade 13,14,15

5. Did you complete college Y/N . What School or University ____________ Date of completion and Degree in what._____________________________

6. Your Place of employment.______________________ Full/Part time_________

7. Your current address. ___________________ Phone number ________Cell_________

8. Please list the names of all children from this marriage and there date of birth and place of birth and there S.S. numbers.

1. ____________ ___________________ _______________

2. ____________ ________________ __________________

3. ____________ ________________ ___________________

9. Are both parents still in same household Y/N If no please list the parent who is no longer in household and a current address for them and the date of move out.

10. Is this the first marriage for both parties? Y/N. If no please list all prior marriage’s and dates of divorce and if there are any children from the marriage and the dates of birth and who they are living with.____________________________________________

_____________________________________________________________________.

11. Do you want to reconcile Y/N?

12. Have you or the family had any family counseling prior to this meeting? Y/N. If yes please list name or name of people who were seen and the name of the counselor with the date of first appointment and ending date.

__________________________________________________________________

13. Do you or your spouse have a person/ attorney that is handling your divorce? Y/N if yes please list the name and...